Job Summary:
The PRC Claims Processor enhances the health status and quality of life of the Tribe and its members by performing administrative duties related to the Purchased Referred Care (PRC) Program. This position plays a vital role in maintaining positive contact with patients, staff, community members, PRC network providers, and others to accomplish Health Center/ PRC objectives and preserve good public relations. This position is regular and full time.
Duties Include:
- Administrative Duties: Monitor and ensure that the outside referral network sufficiently meets PRC eligible members health care needs.
- Help
PRC members access needed care both on and off the Reservation.
- Maintain positive relationships with PRC referral network providers and staff.
- Verify and track eligibility for PRC benefits, Medicare Part A and B eligibility and Part B premium reimbursement and all other applicable alternate resources.
- Maximize the use and coordination of third-party resources for PRC benefits.
- Prepare correspondence to providers and PRC members regarding program changes and additions. This includes engaging in tribal community outreach activities, submitting articles to the weekly memo and monthly newsletter to keep PRC members informed about these types of changes.
- Prepare PRC policy exemption requests for the Health Advisory Committee meeting
- Assist the Health Services management team with PRC policy and procedures planning, development and maintenance.
- Work closely with the Health IT staff to ensure the Plexis A/P software meets PRC program needs.
Clerical Duties:
- Process and pay applicable PRC claims.
- Update the Medicare Like Rates fee schedules as needed.
- Determine eligibility status for new patients.
- Verify benefits for referred services, including processing and monitoring prior-authorizations referrals as needed.
- Track and process PRC reimbursements.
- Assist PRC members with billing questions and concerns.
- Provide on and off the reservation providers with up-to-date eligibility and insurance information. This includes sending out the monthly PRC eligibility list.
- Develop any forms needed to accomplish assigned duties.
- Filing: Set up and maintain needed paper and electronic filing systems in the PRC office.
- Ordering/Inventory of Supplies: Inventories and prepares orders for needed supplies and forms for the PRC program.
- Other duties as assigned by Health Services Manager.
Qualifications:
- Education: G. E. D. or High School diploma required. Prior understanding of eligibility criteria for and the operations of IHS funded PRC benefits desired.
- Thorough knowledge of ADA, CPT and ICD 10 coding preferred.
- Familiarity with medical and dental terminology preferred.
- Background in health claims processing desired, especially in the accounts payable field.
- Current Tribal Assister certification desired. Ability to take and pass the Tribal Assister certification test within the first year of employment required.
Experience:
- Ability to process health information for referral needs necessary.
- Familiarity with referral specialty network for Kitsap County desired.
- Ability to read and comprehend billing and coding manuals and instructions required.
- Ongoing on the job training and ability to change with new State and Federal billing regulations necessary.
- Strong background in case management of health referrals and eligibility issues related to Medicare, Medicaid and other applicable health coverage preferred.
Computer Skills:
- Prior experience with health claims accounts payable and data entry software desired.
- Word, Excel and healthcare related software program knowledge desired.
- Ability to learn to effectively use these types of applications within the first year of employment required.
Interpersonal Relationship Ability:
- Ability to interact with others in a professional and compassionate manner, maintains confidentiality, and work well as a member of a team.
Requirements:
- Regularly required to use hands to finger, handle or feel and talk or hear.
- Frequently required to walk, sit, stand and reach with hands and arms.
- Occasionally required to lift and/or move up to 25 pounds.
- Vision requirements include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
Travel Requirements:
- Local, Statewide and out of state travel may be required.
